Finding into death of Kevin Stanley Margetts

63y · Male·Bowel obstruction

A 63-year-old man with severe intellectual disability, quadriplegia, and blindness died from bowel obstruction with sepsis. On 5 September 2015, carers noted cough and eating difficulties. A locum doctor visited, noted hypotension, respiratory distress, and hard abdomen, administered Microlax, and advised calling an ambulance if symptoms worsened. The patient was admitted to hospital with bowel obstruction, hypoxia, tachycardia, respiratory distress, and sepsis. CT showed markedly distended bowel loops with impending perforation. A decision was made not to escalate treatment. He died the following morning. The coroner found no issues with care provided by the disability support officer. The clinical lesson is that acute bowel obstruction with sepsis and respiratory compromise requires urgent surgical evaluation, though in this case, escalation decisions may have been influenced by the patient's profound disabilities and baseline clinical status.